International Development CommitteeWritten evidence submitted by UK Consortium on AIDS and International Development—TB/HIV Working Group

This submission is made on behalf of the TB/HIV Working Group of the UK Consortium on AIDS and International Development.ⁱ This submission highlights the particular implications of the current Global Fund funding crisis on people affected by TB/HIV co-infection.

Alongside the submission made by UK Coalition to Stop TB,ⁱⁱ this evidence aims to demonstrate the critical role of the Global Fund in ensuring that the UK Government meets their development objectives on TB and HIV.

Summary and Background

The deadly effect of TB and HIV co-infection impedes progress and undermines investments made towards tackling the two diseases. TB/HIV co-infection continues to pose a major public health emergency, particularly in Africa. In 2010, TB caused an estimated 350,000 deaths among people living with HIV.ⁱⁱⁱ

International guidelines recognise that integrated programming is the most effective way to meet the needs of patients.^iv A growing recognition of the effectiveness of service integration led to a significant expansion of TB/HIV services in 2010, particularly in sub-Saharan Africa, which bears the brunt of the dual epidemic.^v

The Global Fund provides for half of all those people receiving treatment for HIV,^vi and supports 83% of international funding for TB. The Fund has played a critical role in supporting countries to better integrate TB and HIV services,^vii along with maternal and child health programmes.

In June 2011, new evidence from scientific modeling released by the Stop TB Partnership, UNAIDS and the World Health Organisation (WHO) illustrated how over the next four years one million TB deaths could be saved among people living with HIV,^viii through the expansion of existing interventions.^ix

However, as a result of the current shortfall in Global fund resources and the cancellation of Global Fund Round 11, the potential gains outlined in this modeling cannot now be achieved.

Recommendations

The UK Government must make good their commitment to the Global Fund by delivering on their promise to increase investment—they should increase their contribution by making an additional commitment of £384 million^x over the three year replenishment period 2011–13.

As a leading donor, the UK Government must support the Global Fund to create a new funding window in 2012 and 2013. The G20 meeting in Mexico in June 2012 provides the ideal opportunity for the UK to make a bold pledge, creating a catalyst for other donors to follow. The role that the UK can play in mobilising new donor commitments should not be under-estimated.

The Current Funding Situation of the Global Fund and DFID’s Contribution to the Fund

Between 2002–10, Global Fund-supported programs provided 2.4 million TB/HIV services, including 530,000 services delivered in 2010 alone.^xi Reflecting the burden of co-infection in the region, sub-Saharan Africa accounted for 65% of the total Global Fund investments for TB/HIV services, and TB grants in the region allocated the majority of their budgets to TB/HIV services and first-line drug treatment.^xii

The Global Plan to Stop TB estimates that the total funding required for TB/HIV interventions is estimated to be US$ 2.8 billion for 2011–15.^xiii Much of this funding would be sourced through the Global Fund, and to deliver results would require a scale up of current activities.

The Global Fund is critical to the delivery of global targets on TB/HIV integration.

Through their multilateral aid review, the UK was the first government to publicly acknowledge how critical the Global Fund is to the delivery of MDG6.^xiv Other international donors, including most recently the Australian Government, have echoed the UK in commending the Global Fund for delivering results for the poorest people^xv through high impact investments.

The Prospects for DFID Achieving its Development Objectives if Current Funding Shortfalls at the Fund are not Addressed

Despite their stated commitment towards the need for TB/HIV integration, DFID have not outlined any specific strategies or targets for this within their bilateral programming. In “Towards Zero Infections: The UK’s position paper on HIV in the developing world”^xvi DFID state that their response to the diseases will be driven through the Global Fund. The delivery of their objectives in this area can therefore only be measured through Global Fund results.

DFID acknowledge that there is a need for more TB/HIV integration within both national programmes and Global Fund applications. The cancellation of round 11, and the restrictive conditions of the Transitional Funding Mechanism (TFM) means that countries will be limited in their capacity to scale up their existing TB/HIV services, or reach new patients.

In “Zero Infections”, DFID state the need to scale up evidence-based prevention for HIV. For example, new evidence has demonstrated the effectiveness of ART in the prevention of HIV and TB.^xvii Whilst early initiation of ART has the potential to fundamentally shift the global response to TB and HIV, countries now have their hands tied due to a lack of funding.

The risk that TB/HIV poses to women^xviii has to date not been adequately addressed within DFID bilateral programming and policy.^xix Global Fund grants support high-impact HIV, TB and malaria interventions across the continuum of pre-pregnancy, pregnancy, birth and childhood. Essential services to reach women and children^xx will be affected by the funding crisis, and subsequently UK objectives to save these lives will not be achieved.

The Impact on People in Developing Countries from the Delay in Funding of New Grants

The TFM is likely to provide funding for essential TB/HIV services in high burden, low-income countries.^xxi However, the TFM does not allow for any scale up of services,^xxii meaning that the ambitious, but not unrealistic target to save an additional million lives, will not be possible. This will have a negative impact on people with TB, including those co-infected with HIV and TB, women and girls with TB, and those infected with multi-drug resistant TB.

People living with HIV (PLWHIV) are at much greater risk of developing multi-drug resistant TB (MDR-TB). Of the 27 high burden MDR-TB countries, 12 are Stop TB Partnership priority countries for TB/HIV. Treating MDR-TB is more difficult and costly but for people living with HIV, MDR-TB can mean a death sentence. Early diagnosis and treatment is critical, but with TFM restrictions on scale up of MDR-TB services, many countries will not be able to respond to this growing threat. With an estimated 440,000 new cases of MDR-TB per year, the majority of which are undiagnosed,^xxiii this should be the time for countries to actively scale up their response, not pull back.^xxiv

Pregnant women are particularly at risk from TB/HIV co-infection, and research in 2009 indicated that 58% of maternal deaths in Zambia were from non-obstetric causes, usually linked to malaria or TB/HIV co-infection.^xxv In Zambia, approximately 80% of people with TB are co-infected. Although progress has been made in Zambia (47% of co-infected patients now receive proper treatment), disruption to existing services is expected when their Global Fund TB grant comes to an end in June 2013. Funding restrictions also mean that Zambia will be unable to scale up its TB response.^xxvi Hospices that provide palliative care and ARVs, are now on the brink of closure, putting more pressure on an already under-resourced national health system.

It has been estimated that 10,732 TB patients and 131,971 people living with HIV in Zambia are at risk due to the funding crisis.^xxvii

Conclusion: The Critical Role of the Global Fund in Saving Lives Worldwide

Critical TB/HIV support services are also now at risk (psychosocial, physical, nutritional, and socio-economic). Without this support, patients are at risk of not completing treatment, leading to loss of life and an increase in cases of drug-resistance. The TFM guidance note does not consider these programme components essential and many of these services may be cut. For patients, this will be devastating.

A scale up of TB/HIV integrated care is the only way that the dual impact of these diseases can be overcome. With the cancellation of round 11, thousands more lives will be lost from TB amongst PLWHIV. The Global Fund must be able to support countries to realise their ambitions to end this unnecessary loss of life.

References

ⁱ More can be found about the working group through this link
http://aidsconsortium.org.uk/working-groups/tb-hiv-working-group/

ⁱⁱ This evidence has been submitted separately through RESULTS UK, who act as the secretariat of the UK Coalition to Stop TB.

ⁱⁱⁱ World Health Organisations (2011). Global Tuberculosis Control 2011. Available from:
http://www.who.int/tb/publications/global_report/en/

^iv World Health Organisation (2012). WHO policy on collaborative TB/HIV activities: guidelines for national programmes and other stakeholders. Available from
http://www.who.int/tb/publications/2012/tb_hiv_policy_9789241503006/en/index.html

^v World Health Organisation (2011). Global tuberculosis control: WHO report 2011
http://www.who.int/tb/publications/global_report/2011/gtbr11_full.pdf—Accessed 27 March 2012.

^vi The Global Fund to Fight AIDS, Tuberculosis and Malaria (2012)
<http://www.theglobalfund.org/en/about/>

^vii The Global Fund provides guidance to Country Coordinating Mechanisms towards integration of TB and HIV programmes—The Global Fund to Fight AIDS, TB and Malaria, Global Fund Information Note: TB/HIV Collaborative Activities (July 2011).

^viii Time to act: Save a million lives by 2015, Stop TB Partnership (2011). Available from:
http://www.stoptb.org/assets/documents/resources/publications/acsm/TB_HIV_Brochure_Singles.pdf

^ix Such as antiretroviral therapy and the “three I’s”: Isoniazid preventive therapy (IPT), intensified TB case-finding among people with HIV, and infection control to prevent the spread of TB in health facilities.

^x This figure may vary across submissions due to exchange rate fluctuations. Fair share calculations were made in dollars, with the UK’s being $1.245 billion. In 2010 that equated to approximately £840 million. Today it is closer to £780 million. The fact remains that the UK must more than double its contribution for this replenishment period (2011–13) to reach its fair share—at least an additional £384 million.

^xi The Global Fund to Fight AIDS, TB and Malaria, Making a Difference, Global Fund Results Report 2011.

^xii The Global Fund to Fight AIDS, TB and Malaria, Making a Difference: Sub-Saharan Africa—Regional Results Report 2011.

^xiii Stop TB Partnership, WHO (2011). The Global Plan to Stop TB 2011–15.

^xiv UK Government multilateral Aid Review
http://www.dfid.gov.uk/Documents/publications1/mar/multilateral_aid_review.pdf
Accessed 2 April 2012.

^xv See AusAid assessment of the Global Fund (April 2012)
http://www.ausaid.gov.au/partner/pdf/ama/ama-individual-assessments/global-fund-assessment.pdf. Accessed 2.4.12

^xvi DFID (2011). Towards Zero Infections: The UK’s position paper on HIV in the developing world, available from: http://www.dfid.gov.uk/Documents/publications1/twds-zero-infs-pos-paper-hiv-dev-wrld.pdf

^xvii World Health Organisation (2011). ART in the prevention of HIV and TB
http://www.who.int/hiv/topics/tb/faq_art_prevention_hiv_and_tb_revised_april_2011.pdf.
Accessed 27 March 2012.

^xviii See this link for more information on the impact of TB/HIV on women
http://www.action.org/site/get_educated/tuberculosis_an_unchecked_killer_of_women

^xix Despite the impact of TB/HIV on women, no indicators for TB/HIV screening and treatment were included in the DFIDs Framework for Results for Reproductive, maternal and newborn health
http://www.dfid.gov.uk/rmnh

^xx See this blog for a personal account of the impact on TB and HIV on children
http://www.action.org/blog/post/tb_and_hiv_a_deadly_combination_for_children

^xxi This includes HIV testing and treatment among TB patients, TB preventive therapy amongst PLWHA and TB screening among high-risk populations. The TFM also allows for ??????

^xxii Including the utilisation of new evidence around ARVs as well as scaling up new technologies for better diagnosis of TB (such as the Genexpert machine).

^xxiii The Global Fund to Fight AIDS, TB and Malaria (2011). Making a Difference, Global Fund Results Report 2011.

^xxiv Medicins Sans Frontieres (2012). Lives in the Balance: the urgent need for HIV and TB Treatment in Myanmar
http://www.msf.org/shadomx/apps/fms/fmsdownload.cfm?file_uuid=504B3A4A-9A59-4F3B-9F99-13A8D08A38EC&siteName=msf

^xxv The Global Fund to Fight AIDS, TB and Malaria (2011), Making a Difference: Sub-Saharan Africa—Regional Results Report 2011.

^xxvi Including; strengthening intensified TB case finding; increasing scale-up of isoniazid preventive therapy, and getting patients a better and more accurate diagnosis using new technologies. The Genexpert machine has proved more effective in diagnosing TB and MDR-TB in patients. Government plans to improve M&E of TB and TB/HIV co-infection in order to better inform their response to the two diseases, will be affected.

^xxvii International HIV/AIDS Alliance (2012). Don’t Stop Now: How Underfunding the Global Fund to Fight AIDS, Tuberculosis and Malaria Impacts the HIV response.
<http://www.aidsalliance.org/includes/Publication/Alliance%20global%20fund%20report_V6.pdf>

March 2012